Many rules cloud good judgement

Friends in low places By James Willis Radcliffe Medical Press 232 pages£19.95 James Willis has written a book of anecdotes and analysis, insights and belief.

Its central thesis is that direction of travel of health (and education) - towards counting and ticking boxes - is fundamentally flawed.

He maintains that the GP role and the delivery of health services are in danger of getting lost in the welter of central diktats and slavish adherence to evidence-based care. The assumed wisdom that medicine is a mix of science and art has been subverted by post-modern extravagance that there is an answer to everything and that clinical judgement can be replaced by protocols and national frameworks.

The anecdotes come from his 25 years' experience of general practice.His insight stems from involvement in journalism and a view that we have become over-concerned with rare events that should 'never happen again'.

This includes such things as the murderous life of Dr Harold Shipman which, Willis says, hampers us in dealing with, and truly 'seeing', the real issues. 'Perfection is never achievable and the further we go towards it, the steeper the path... We are paralysed by an enhanced view of danger.'

He widens the argument to explore the undermining parents', patients' and doctors' authority.

The first refers to the cases of parents arrested after allegations of 'minor physical correction' by their adopted children. The second that patients are often allowed to buy aspirin for themselves in expensive small packs only.

Last, but not least, he cites the fact that doctors, instead of being allowed to exercise their professional judgement, are expected to adhere to clinical protocols and become believers in the primacy of 'managerialism'.

Doctors are now warned that the failure to follow guidance from the National Institute for Clinical Excellence may result in litigation by patients in the case of an adverse outcome.

They are told that arguments for any deviation from the guidance should be put in writing, in patients' notes.

Trust, once the hallmark of the professional, is therefore also undermined. 'Protocols are petrified thinking... the idea that they are better than thinking... is a whirlpool into which our society is being sucked, ' states Willis.

Many clinicians and managers will agree that slavish adherence to rules is not wise and that 'being a professional' is judging when and when not to follow rules.

The decision to inject an emergency drug that is one week out of date is one teasing example.

Willis, I hope playfully, suggests restricting appraisals because 'we know when something is working' and demoting 'equal ops'when appointing staff .He perhaps ignores the saying that 'doctor knows best' is and will continue to be contestable and contested.

Less controversially, the book documents information overload, suggesting that daily life is too full and that today the skill is in deciding what not to read and when to say 'no' to yet another task 'that only adds 30 seconds to the consultation'.

Willis suggests a computer works well with models of life and disease but fails in the reality of the consultation.

IT, he asserts, empowers by helping people, not controlling them.

He calls for a re-balancing between professional autonomy and accountability;

empowerment and control by 'over-available' information;

and between common (professional) sense and strict protocol.His balance point may help you re-adjust yours.

Financial penalties are being lifted from high-profile standards including cancer and elective waiting times, so far without attracting much attention. How is this happening? And will it work, asks Rob Findlay